Liquid gold: Lessons learned on the job

2015 10 12 12 16 52 156 Golden Drop 200

Some of you will recall my first article about simple rules of radiology -- the 26 uber-truths that are the very essence of our dear specialty. Well, it's taken two and half years, but I've now come up with another batch of new rules. And remember, you must obey the rules ...

Rule 27: Radiologists don't wear suede shoes
Or brogues, open-toed shoes, or sandals. When you understand the concept of secondhand barium, you'll know why.

Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.
Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

Rule 28: Reporting rooms should be pitch black
If you report with the lights on, you are letting the entire profession down. This is for logical visual reasons, but it also handily disorientates those who trespass into the room.

Rule 29: Don't touch the screens
Not with greasy fingers, never ever with pens. The dirtier the screen you'll tolerate, the sloppier a radiologist you are.

Rule 30: Never investigate on the day of discharge
These tests always turn up something unexpected that is usually ultimately benign but takes another week to sort out.

Rule 31: Only give clinicians 15 seconds
If they can't cut to the chase, help them. We haven't got all day. The longer the preamble, the lower the pretest probability.

Rule 32: You can never know too much anatomy
The more anatomy you know, the better the radiologist you become. It's the only thing you learn at medical school that won't have changed by the time you retire.

Rule 33: Be careful with "limited" or "quick" studies
Guaranteed you'll miss the cancer. Better off doing the whole thing or nothing at all.

Rule 34: Image quality is up to the radiologist
Image noise, coverage, adequacy of position, and so on are all dictated by what you are willing accept, not by what was produced.

Rule 35: It is never a chordoma
Rare presentation of a common disease is commoner than common presentation of a rare disease. That classical rare bone lesion is usually just another bone metastasis.

Rule 36: Error is inherent to radiology
Get used to it. The images are subjective. Every cancer starts really, really small. The human body is really, really complex.

Rule 37: Savor mistakes
And near misses too. Even the best radiologists can make the worst mistakes -- you cannot know it all. But everyone can learn.

Rule 38: Don't rush a report
Clinicians bizarrely expect it instantly. The more complex the scan, the sicker the patient, the closer they crowd you. Dispel them with, "You can have the wrong report now or the correct report in 15 minutes."

Rule 39: Never wake up a patient.
If they are sound asleep, they don't need a scan right now. Sleep is good for ill people.

Rule 40: Know about esoterica
If you hear hoof beats and see stripes, it could be a zebra. There are so many rare conditions that it is common to have at least one of them in the hospital.

Rule 41: Doctors aren't porters
If you let them just "drop off a form" and leave without another word, then you are doing them, you, and the patient a disservice.

Rule 42: Don't shoot the messenger
It isn't the poor junior doctor's fault that the "surgeons want a CT before they see the patient." Instead of ripping them a new orifice, save your anger for the original miscreant.

Rule 43: Question "protocols"
If the major reason for a scan is due to "the protocol," ask to see it "for my education." The protocol in question usually either doesn't exist or states exactly the contrary.

Rule 44: Don't be a hairdresser
Hairdressers never say, "You don't need a haircut." Question the motives of those who are paid per scan, especially when they recommend expensive additional studies.

Rule 45: Prognostication is not an indication
If someone is so ill that they are not fit for a haircut, then a scan isn't going to change anything. It is wasting everyone's time.

Rule 46: Beware of Mr. Twitchy
If a patient can't stay still, abandon the scan straight away. Get them back another time. Otherwise you get asked to interpret a twitchogram. And that never ends well.

Rule 47: Always look at the scout image or localizers
That 10 cm renal cell carcinoma isn't on the sagittal T2-weighted MRI. And that basal lung cancer isn't on the volume dataset.

Rule 48: Dictate considerately
If a secretary six rooms away can clearly transcribe your every word, you should probably speak a little more quietly. You are also probably irritating your colleagues beyond belief.

Rule 49: Don't scan instead of talking
Resist pressure to omit clinical discussion. Talking is cheap, quick, and can avoid scans altogether. It also has relatively few serious side effects.

Rule 50: Never scan the dying
It is highly distressing, undignified, and tantamount to assault. No amount of diagnostic electromagnetic waves will stop Mother Nature.

Rule 51: Don't be a smart arse
Scans often only become a waste of time after you've done them. It's easy to be wise with hindsight: only a facile radiologist does this.

Rule 52: False positives are errors too
Overcalling is an equal sin to undercalling. If you can't report a chest x-ray without asking for a CT, you need to take a long hard look at yourself.

Rule 53: Vetting requests is worthwhile
If you let other people do it for you, you cannot complain about unjustified scans or scrambled clinical reasoning. Man up and get on with it.

Rule 54: Be a holistic radiologist
Look at the whole image, not just your area of specialist interest. You may be the cleverest spinal radiologist since the Earth cooled, but missing an abdominal aortic aneurysm isn't terribly clever.

Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.

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